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    Evaluating Outcomes of Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears

    Editor’s Note: Research papers intended for presentation at the canceled annual meeting of the American Academy of Orthopaedic Surgeons are now available online at the AAOS Virtual Education Experience. We’ll be highlighting a few of the more interesting papers throughout the summer.

    Certain irreparable rotator cuff tears exhibit loss of humeral head containment in the glenoid fossa, which occurs because of varying contributions of ineffective active and passive constraint mechanisms. Because it no longer has anterosuperior constraint, the humeral head migrates, often exhibiting a reduction in the acromial-humeral distance. [1-4] Functional abnormalities and pseudoparalysis may result.

    Active constraint can sometimes be restored with partial rotator cuff repair or tendon transfer if balanced force couples can be reestablished. Reconstruction of the superior capsule has also been proposed to improve the rotator cuff-deficient shoulder by improving passive constraint at the initiation of glenohumeral elevation.

    Surgical management of irreparable or functionally irreparable rotator cuff tears is challenging. Primary repair to the insertion site on the tuberosities is either not possible intraoperatively due to the size of the lesion and retraction or deemed futile preoperatively because of muscle impairment from fatty infiltration and atrophy. [5,6] Alternatives to primary repair, including debridement and tenotomy, tendon transfers, and reverse total shoulder arthroplasty, have been attempted, with mixed results and high rates of complication. [7-13]

    RELATED: The Evolution of the Superior Capsular Reconstruction Technique

    In 2013, Mihata et al [1] first described their technique for superior capsular reconstruction (SCR), an alternative to other, less-successful surgical options for managing irreparable rotator cuff tears. During the procedure, a graft is used to recreate the superior capsule, which restores passive constraint in the shoulder, thus increasing function and reducing pain. Multiple authors have described variations on the SCR technique since 2013. [14-20]

    A new retrospective study from Hospital for Special Surgery (HSS) adds to the literature on SCR. Researchers there evaluated clinical outcomes of arthroscopic SCR performed with a dermal allograft in 72 patients with symptomatic irreparable rotator cuff tears. All patients were operated on by fellowship-trained sports medicine and shoulder specialists at HSS between 2012 and 2017. They recorded data on:

    • Patient demographics
    • Previous treatment history
    • Preoperative and postoperative range of motion (ROM)
    • Preoperative imaging
    • Postoperative patient-reported outcome scores (Single Assessment Numeric Evaluation [SANE], American Shoulder and Elbow Surgeons [ASES], and University of California at Los Angeles [UCLA])

    Mean patient age at the time of surgery was 62 years, and 42% of patients had a history of failed rotator cuff repair.

    The researchers saw significant improvement in ROM after SCR:

    • Forward elevation: 81.5° preoperatively to 155.9° postoperatively (P<0.001)
    • Abduction: 46.4° preoperatively to 145.9° postoperatively (P<0.001)
    • External rotation: 28.7° preoperatively to 66.6° postoperatively (P<0.001)

    Patients reported high scores on the 3 outcome measures at a mean follow-up of 11.1 ± 8.4 months (range 3-33 months): 80% for SANE, 78% for ASES, and 85% for UCLA.

    “This technique has proven to be effective for patients with irreparable tears,” said Joshua S. Dines, MD, senior study author and a sports medicine surgeon at HSS. “As we continue to do more outcomes research, we become more precise at predicting the best candidates for each technique. While not for everyone, (SCR) has emerged as a great option for patients who may not be right for a reverse shoulder replacement.”

    The authors are planning future research evaluating the long-term outcomes of SCR for irreparable rotator cuff tears.

    Source

    Hurwit D, Chan J, Fu M, Apostolakos J, Fealy S, Cordasco F, Dines D, Gulotta L, Dines J. Clinical Outcomes following Arthroscopic Shoulder Superior Capsular Reconstruction, Paper 209. AAOS Virtual Education Experience.

    References

    1. Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013; 29(3):459-470.
    2. Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon tears. Am J Sports Med. 2015; 44(1):191-197.
    3. Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon. Am J Sports Med. 2016; 44(6):1423-1430.
    4. Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012; 40(10):2248-2255.
    5. Dines DM, Moynihan DP, Dines J, McCann P. Irreparable rotator cuff tears: what to do and when to do it; the surgeon’s dilemma. J Bone Joint Surg Am. 2006;88(10):2294–2302
    6. Merolla G, Chillemi C, Franceschini V, et al. Tendon transfer for irreparable rotator cuff tears: indications and surgical rationale. Muscles Ligaments Tendons J. 2015;4:425–432.
    7. Bedi A, Dines J, Warren RF, Dines DM. Massive tears of the rotator cuff. J Bone Joint Surg Am. 2010; 92(9):1894-1908.
    8. Boileau P, Sinnerton RJ, Chuinard C, Walch G. Arthroplasty of the shoulder. J Bone Joint Surg Br. 2006; 88-B:562-575.
    9. Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elbow Surg. 2013; 22(9):1199-1208.
    10. Gavriilidis I, Kirch J, Mogasch P, Lichtenberg S, Habermeyer P. Pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears. Int Orthop. 2010; 34(5):689-694.
    11. Grimberg J, Kany J, Valenti P, Amaravathi R, Ramalingam AT. Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears. Arthroscopy. 2015; 31(4):599-607.
    12. Kim SJ, Lee IS, Kim SH, Lee W, Chun YM. Arthroscopic partial repair of irreparable to massive rotator cuff tears. Arthroscopy. 2012; 28(6):761-768.
    13. Lee BG, Nam SC, Rhee YG. Results of arthroscopic decompression and tuberoplasty for irreparable massive rotator cuff tears. Arthroscopy. 2011; 27(10):1341-1350.
    14. Hirahara AM, Adams CR. Arthroscopic superior capsular reconstruction for the treatment of massive irreparable rotator cuff tears. Arthrosc Tech. 2015; 4(6):e637-e641.
    15. Adams CR, Denard PJ, Brady PC, Hartzler RU, Burkhart SS. The arthroscopic superior capsular reconstruction. Am J Orthop. 2016; 45(5):320-324.
    16. Burkhart SS, Denard PJ, Adams CR, Brady PC, Hartzler RU. Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair. Arthrosc Tech. 2016; 5(6):e1407-e1418.
    17. Narvani AA, Consigliere P, Polyzois I, Sarkhel T, Gupta R, Levy O. The “pull-over” technique for arthroscopic superior capsular reconstruction. Arthrosc Tech. 2016; 5(6):e1441-1447.
    18. Petri M, Greenspoon JA, Millett PJ. Arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthrosc Tech. 2015; 4(6):e751-e755.
    19. Sutter EG, Godin JA, Garrigues GE. All-arthroscopic superior shoulder capsule reconstruction with partial rotator cuff repair. Orthopedics. 2017; 40(4):e735-e738.
    20. Tokish JM, Beicker C. Superior capsule reconstruction technique using an acellular dermal allograft. Arthrosc Tech. 2015; 4(6):e833-e839.